CONCEPT DOCUMENTATION NUTRITIONAL CARE
Individual/Population Interacts with Nutrition Professional
a. Nutrition Assessment and Re-Assessment
1. Obtain or collect relevant data
2. Analyze or interpretation of collected data
b. Nutrition Diagnosis
1. P: Identify the Problem
2. E: Determine the Etiology or cause
3. S: Signs and symptoms
c. Nutrition Intervention
1. Define interventions and prescriptions
2. Formulate goals and determine actions
3. Implementing action
d. Nutrition Monitoring and Evaluation
1. Selects or identifies quality indicators
2. Monitor and evaluate diagnosis completion
Definition of documentation
• Process of collecting, selecting, processing, and storage of information in the field of
knowledge
• the provision or collection of evidence from information such as pictures, quotations,
newspaper, cuttings newspapers, and other reference materials
Purpose of documentation
• Means of communication
• As a responsibility
• For statistical information
• Education
• Source of research data
• Service quality assurance
• Source of data for sustainable nutrition care services
• As a provider of data / patient history for further treatment from other health teams
